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JLC 7th Grade Registration 2023-24
Please verify reCaptcha before submitting the form.
Thank you for registering as soon as possible!
Parent Information
*
First name
*
Last name
*
Email
*
Have you already registered a younger child for TK-6th grade?
Please Select One
Yes, I/we have already registered a TK-6th student with the JLC
No, I am/we are only registering a 7th grade student with the JLC
If so, we will use your biographical information responses from the other form.
What is your Hebrew name (if you have one)? Please write in transliteration if so.
*
Cell phone
Work phone
Preferred methods of communication (select all that apply)
email
phone - call
phone - text
Social media - Instagram and/or Facebook
Gender
Male
Female
Non-binary
Other
What are your preferred pronouns?
he/him
she/her
they/them
Other
*
Relationship to child(ren)
Please Select One
Mother
Father
Step-parent
Other
Relationship status
Married
Single
Widowed
Divorced
Partnered
Occupation
*
Street Address
Street Address Line 2
*
City
*
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
ZIP Code
*
Would you like to add a second parent/guardian?
Please Select One
Yes
No
*
First name
*
Last name
What is your Hebrew name (if you have one)? Please write in transliteration if so.
*
Cell phone
Work phone
*
Email
Preferred methods of communication (select all that apply)
email
phone - call
phone - text
Social media - Instagram and/or Facebook
Gender
Male
Female
Non-binary
Other
What are your preferred pronouns?
he/him
she/her
they/them
Other
*
Relationship to child(ren)
Please Select One
Mother
Father
Step-parent
Other
Relationship status
Married
Single
Widowed
Divorced
Partnered
Occupation
*
Is this parent/guardian's address different from the above?
Please Select One
No
Yes
*
Street Address
Street Address Line 2
*
City
*
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
ZIP Code
*
Child(ren) live(s) with:
Please Select One
Parent/Guardian 1 & 2 together
Parent/Guardian 1 & 2 but in separate residences
Parent/Guardian 1 only
Parent/Guardian 2 only
Other
Child Information
*
Child 1's first name
*
Child 1's last name
Child 1's Hebrew name (write in transliteration)
*
Child 1's date of birth
*
Child 1's Gender
Please Select One
Male
Female
Non-binary
Other
*
Child 1's preferred pronouns (optional)
Please Select One
he/him
she/her
they/them
Other
*
Secular school district:
Please Select One
Los Angeles Unified School District (LAUSD)
Las Virgenes Unified School District (LVUSD)
Oak Park Unified School District (OPUSD)
Conejo Valley Unified School District (CVUSD)
Private
Other
*
LVUSD school:
Please Select One
AC Stelle MS
AE Wright MS
Lindero Canyon MS
Other
*
LAUSD school:
Please Select One
Columbus MS
Hale MS
Other
*
If other school district or other school within LAUSD and LVUSD, please note it here:
Child Medical Information
*
Child 1's doctor's name
*
Child 1's doctor's phone number
*
Child 1's medical insurance carrier
*
Child 1's medical insurance policy number or Kaiser record number
*
Child 1's dentist's name
*
Child 1's dentist's phone number
*
Child 1's dental insurance carrier
*
Child 1's dental insurance policy number
*
As of July 1, 2023, is this child up-to-date on required immunizations for their age?
Please Select One
Yes
No
*
Does this child take medication?
Please Select One
No
Yes
*
Please list ALL medication names
*
Will any of your child's medications need to be kept and/or possibly administered by the JLC?
Please Select One
No
Yes
(i.e. an inhaler or any other medication that would need to be given during school hours)
*
Please give detailed instructions on which medications we will need to keep and/or administer to this child
*
Does this child have allergies?
Please Select One
No
Yes
*
Please list ALL allergies
*
Does this child's allergy (or allergies) necessitate any special behavior from the staff/administration of the JLC?
Please Select One
No
Yes
*
Please give detailed instructions on how this child's allergy (or allergies) necessitate any special behavior from the staff/administration of the JLC
For example, "my child cannot be in a room with flowers, etc." Please note that the JLC is a nut-free (both peanut and tree-nut) school.
Child Educational Information
*
What would you like us to know about your child? Who are they, and what should we know about them?
Tell us a little bit about who your child is. Also, please describe any educational or social/emotional concerns we should know about your child.
*
Has this child ever been evaluated for educational or social/emotional concerns?
Please Select One
No
Yes
*
What did you learn from that evaluation that can help us best facilitate and support this child's learning?
*
Vision-related concerns?
Please Select One
No
Yes
*
If yes, please elaborate on this child's vision concerns
Examples: wears glasses, wears contact lenses, color-blind, visual processing disorder, or another
*
Reading Concerns?
Please Select One
No
Yes
*
If yes, please elaborate on this child's reading challenges
Examples: dyslexia, reads below grade level, difficulty understanding or processing written information, or other
*
Auditory challenges?
Please Select One
No
Yes
*
If yes, please elaborate on this child's auditory challenges
Examples: hearing impairment, auditory processing disorder, difficulty understanding/processing spoken/oral information, or other
*
Attention challenges?
Please Select One
No
Yes
*
If yes, please elaborate on this child's attention challenges
Examples: ADHD, tends to be easily distracted, tends to be hyperactive, or other
Please add any other important information you think we should know about this child.
Desired Day of Attendance
*
Desired Day of JLL Attendance
Please Select One
Tuesdays 6-8pm
Wednesdays 4-6pm
Would you like to register a second child?
Please Select One
No
Yes
Child 2's Information
*
Child 2's first name
*
Child 2's last name
Child 2's Hebrew name (write in transliteration)
*
Child 2's date of birth
*
Child 2's Gender
Please Select One
Male
Female
Non-binary
Other
Child 2's preferred pronouns (optional)
he/him
she/her
they/them
Other
*
Does child 2 go to the same school as child 1?
Please Select One
Yes, they do
No, they go to a different school
*
Secular school district:
Please Select One
Los Angeles Unified School District (LAUSD)
Las Virgenes Unified School District (LVUSD)
Oak Park Unified School District (OPUSD)
Conejo Valley Unified School District (CVUSD)
Private
Other
*
LVUSD school:
Please Select One
AC Stelle MS
AE Wright MS
Lindero Canyon MS
Other
*
LAUSD school:
Please Select One
Columbus MS
Hale MS
Other
*
If other school district or other school within LAUSD and LVUSD, please note it here:
Child 2's Medical Information
*
Child 2's doctor's name
*
Child 2's doctor's phone number
*
Child 2's medical insurance carrier
*
Child 2's medical insurance policy number or Kaiser record number
*
Does child 2 have the same dental information as child 1?
Please Select One
Yes, it's the same
No, it's different
*
Child 2's dentist's name
*
Child 2's dentist's phone number
*
Child 2's dental insurance carrier
*
Child 2's dental insurance policy number
*
As of July 1, 2023, is this child up-to-date on required immunizations for their age?
Please Select One
Yes
No
*
Does this child take medication?
Please Select One
No
Yes
*
Please list ALL medication names
*
Will any of your child's medications need to be kept and/or possibly administered by the JLC?
Please Select One
No
Yes
(i.e. an inhaler or any other medication that would need to be given during school hours)
*
Please give detailed instructions on which medications we will need to keep and/or administer to this child
*
Does this child have allergies?
Please Select One
No
Yes
*
Please list ALL allergies
*
Does this child's allergy (or allergies) necessitate any special behavior from the staff/administration of the JLC?
Please Select One
No
Yes
*
Please give detailed instructions on how this child's allergy (or allergies) necessitate any special behavior from the staff/administration of the JLC
For example, "my child cannot be in a room with flowers, etc." Please note that the JLC is a nut-free (both peanut and tree-nut) school.
Child 2's Educational Information
*
What would you like us to know about your child? Who are they, and what should we know about them?
Tell us a little bit about who your child is. Also, please describe any educational or social/emotional concerns we should know about your child.
*
Has this child ever been evaluated for educational or social/emotional concerns?
Please Select One
No
Yes
*
What did you learn from that evaluation that can help us best facilitate and support this child's learning?
*
Vision-related concerns?
Please Select One
No
Yes
*
If yes, please elaborate on this child's vision concerns
Examples: wears glasses, wears contact lenses, color-blind, visual processing disorder, or another
*
Reading Concerns?
Please Select One
No
Yes
*
If yes, please elaborate on this child's reading challenges
Examples: dyslexia, reads below grade level, difficulty understanding or processing written information, or other
*
Auditory challenges?
Please Select One
No
Yes
*
If yes, please elaborate on this child's auditory challenges
Examples: hearing impairment, auditory processing disorder, difficulty understanding/processing spoken/oral information, or other
*
Attention challenges?
Please Select One
No
Yes
*
If yes, please elaborate on this child's attention challenges
Examples: ADHD, tends to be easily distracted, tends to be hyperactive, or other
Please add any other important information you think we should know about this child.
Child 2's Desired Day of Attendance:
*
Desired Day of Attendance
Please Select One
Tuesdays 6-8pm
Wednesdays 4-6pm
Would you like to add a third child?
Please Select One
No
Yes
Child 3's Information
*
Child 3's first name
*
Child 3's last name
Child 3's Hebrew name (write in transliteration)
*
Child 3's date of birth
*
Child 3's Gender
Please Select One
Male
Female
Non-binary
Other
Child 3's preferred pronouns (optional)
he/him
she/her
they/them
Other
*
Does child 3 go to the same school as child 1?
Please Select One
Yes, they do
No, they go to a different school
*
Secular school district:
Please Select One
Los Angeles Unified School District (LAUSD)
Las Virgenes Unified School District (LVUSD)
Oak Park Unified School District (OPUSD)
Conejo Valley Unified School District (CVUSD)
Private
Other
*
LVUSD school:
Please Select One
AC Stelle MS
AE Wright MS
Lindero Canyon MS
Other
*
LAUSD school:
Please Select One
Columbus MS
Hale MS
Other
*
If other school district or other school within LAUSD and LVUSD, please note it here:
Child 3's Medical Information
*
Child 3's doctor's name
*
Child 3's doctor's phone number
*
Child 3's medical insurance carrier
*
Child 3's medical insurance policy number or Kaiser record number
*
Does child 3 have the same dental information as child 1?
Please Select One
Yes, it's the same
No, it's different
*
Child 3's dentist's name
*
Child 3's dentist's phone number
*
Child 3's dental insurance carrier
*
Child 3's dental insurance policy number
*
As of July 1, 2023, is this child up-to-date on required immunizations for their age?
Please Select One
Yes
No
*
Does this child take medication?
Please Select One
No
Yes
*
Please list ALL medication names
*
Will any of your child's medications need to be kept and/or possibly administered by the JLC?
Please Select One
No
Yes
(i.e. an inhaler or any other medication that would need to be given during school hours)
*
Please give detailed instructions on which medications we will need to keep and/or administer to this child
*
Does this child have allergies?
Please Select One
No
Yes
*
Please list ALL allergies
*
Does this child's allergy (or allergies) necessitate any special behavior from the staff/administration of the JLC?
Please Select One
No
Yes
*
Please give detailed instructions on how this child's allergy (or allergies) necessitate any special behavior from the staff/administration of the JLC
For example, "my child cannot be in a room with flowers, etc." Please note that the JLC is a nut-free (both peanut and tree-nut) school.
Child 3's Educational Information
*
What would you like us to know about your child? Who are they, and what should we know about them?
Tell us a little bit about who your child is. Also, please describe any educational or social/emotional concerns we should know about your child.
*
Has this child ever been evaluated for educational or social/emotional concerns?
Please Select One
No
Yes
*
What did you learn from that evaluation that can help us best facilitate and support this child's learning?
*
Vision-related concerns?
Please Select One
No
Yes
*
If yes, please elaborate on this child's vision concerns
Examples: wears glasses, wears contact lenses, color-blind, visual processing disorder, or another
*
Reading Concerns?
Please Select One
No
Yes
*
If yes, please elaborate on this child's reading challenges
Examples: dyslexia, reads below grade level, difficulty understanding or processing written information, or other
*
Auditory challenges?
Please Select One
No
Yes
*
If yes, please elaborate on this child's auditory challenges
Examples: hearing impairment, auditory processing disorder, difficulty understanding/processing spoken/oral information, or other
*
Attention challenges?
Please Select One
No
Yes
*
If yes, please elaborate on this child's attention challenges
Examples: ADHD, tends to be easily distracted, tends to be hyperactive, or other
Please add any other important information you think we should know about this child.
Child 3's Desired Day of Attendance:
*
Desired Day of Attendance
Please Select One
Tuesdays 6-8pm
Wednesdays 4-6pm
Would you like to add a fourth child?
Please Select One
No
Yes
Child 4's Information
*
Child 4's first name
*
Child 4's last name
Child 4's Hebrew name (write in transliteration)
*
Child 4's date of birth
*
Child 4's Gender
Please Select One
Male
Female
Non-binary
Other
Child 4's preferred pronouns (optional)
he/him
she/her
they/them
Other
*
Does child 4 go to the same school as child 1?
Please Select One
Yes, they do
No, they go to a different school
*
Secular school district:
Please Select One
Los Angeles Unified School District (LAUSD)
Las Virgenes Unified School District (LVUSD)
Oak Park Unified School District (OPUSD)
Conejo Valley Unified School District (CVUSD)
Private
Other
*
LVUSD school:
Please Select One
AC Stelle MS
AE Wright MS
Lindero Canyon MS
Other
*
LAUSD school:
Please Select One
Columbus MS
Hale MS
Other
*
If other school district or other school within LAUSD and LVUSD, please note it here:
Child 4's Medical Information
*
Child 4's doctor's name
*
Child 4's doctor's phone number
*
Child 4's medical insurance carrier
*
Child 4's medical insurance policy number or Kaiser record number
*
Does child 4 have the same dental information as child 1?
Please Select One
Yes, it's the same
No, it's different
*
Child 4's dentist's name
*
Child 4's dentist's phone number
*
Child 4's dental insurance carrier
*
Child 4's dental insurance policy number
*
As of July 1, 2023, is this child up-to-date on required immunizations for their age?
Please Select One
Yes
No
*
Does this child take medication?
Please Select One
No
Yes
*
Please list ALL medication names
*
Will any of your child's medications need to be kept and/or possibly administered by the JLC?
Please Select One
No
Yes
(i.e. an inhaler or any other medication that would need to be given during school hours)
*
Please give detailed instructions on which medications we will need to keep and/or administer to this child
*
Does this child have allergies?
Please Select One
No
Yes
*
Please list ALL allergies
*
Does this child's allergy (or allergies) necessitate any special behavior from the staff/administration of the JLC?
Please Select One
No
Yes
*
Please give detailed instructions on how this child's allergy (or allergies) necessitate any special behavior from the staff/administration of the JLC
For example, "my child cannot be in a room with flowers, etc." Please note that the JLC is a nut-free (both peanut and tree-nut) school.
Child 4's Educational Information
*
What would you like us to know about your child? Who are they, and what should we know about them?
Tell us a little bit about who your child is. Also, please describe any educational or social/emotional concerns we should know about your child.
*
Has this child ever been evaluated for educational or social/emotional concerns?
Please Select One
No
Yes
*
What did you learn from that evaluation that can help us best facilitate and support this child's learning?
*
Vision-related concerns?
Please Select One
No
Yes
*
If yes, please elaborate on this child's vision concerns
Examples: wears glasses, wears contact lenses, color-blind, visual processing disorder, or another
*
Reading Concerns?
Please Select One
No
Yes
*
If yes, please elaborate on this child's reading challenges
Examples: dyslexia, reads below grade level, difficulty understanding or processing written information, or other
*
Auditory challenges?
Please Select One
No
Yes
*
If yes, please elaborate on this child's auditory challenges
Examples: hearing impairment, auditory processing disorder, difficulty understanding/processing spoken/oral information, or other
*
Attention challenges?
Please Select One
No
Yes
*
If yes, please elaborate on this child's attention challenges
Examples: ADHD, tends to be easily distracted, tends to be hyperactive, or other
Please add any other important information you think we should know about this child.
Child 4's Desired Day of Attendance:
*
Desired Day of Attendance
Please Select One
Tuesdays 6-8pm
Wednesdays 4-6pm
Emergency Contact Information
*
If we cannot reach you or your spouse/partner, who is your best emergency contact?
This is someone other than you or your spouse/partner!
*
Emergency contact's relationship to child(ren)
Examples: grandmother, uncle, family friend, babysitter
*
Emergency contact's phone number
Pick-up and Drop-off
*
Will your child(ren) be regularly dropped off and/or picked up by someone other than their parent/guardian (or another synagogue member)?
Please Select One
No, my partner/spouse or I will pick them up
Yes, someone other than myself or my spouse/partner will pick them up
Is this person a synagogue member?
Yes
No
*
Pick-up / Drop-off person's name
*
Pick-up / Drop-off person's relationship to child(ren)
Examples: babysitter, nanny, grandparent, other relative
*
Pick-up / Drop-off person's phone number
Medical Waiver
I/We do herby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered to said minor under the general or special instructions of our physician or other physician called in any emergency by the principal, rabbi, or responsible adult in the event I/we cannot be reached; whether such diagnosis or treatment is rendered at the office of said physician, at a licensed hospital, or by emergency medical services. It is understood that conscientious effort will be made to notify me or another parent/guardian listed above before such action is taken; but, if such efforts are unsuccessful, the expense of this service will be accepted by me. It is understood that this consent is given in advance of any specific diagnosis or treatment being required. This consent shall remain effective until revoked.
*
I consent
I consent
*
E-Signature: Your full name
*
Today's date
Additional Information
Virtual Image Policy
The hamakom website, print publications, and social media are tools to communicate with synagogue families families, students, teachers, prospective families and students, and the larger Jewish community. To enhance this experience, we use photos and videos to show student involvement in various JLC activities. On rare occasions, we will invite the local media to our campus to cover an event, and your child's picture may be taken. At no time are any child’s names associated with a photograph. Please feel free to contact Rabbi Adam at rabbiadam@thejlc.net or Rae Antonoff at rae@thejlc.net should you have any questions.
Parent Volunteers
Jewish education is a partnership between families and the synagogue. Both are vital components in a successful program. Throughout the year, we rely on parents for help in the classrooms and at special events, to serve on our education committee, and to share your skills and talents.
*
Would you or someone else in your family be interested in volunteer opportunities at the JLC throughout the school year?
Please Select One
Yes
No
Parent Partners
Parent Partners give parents a voice and a hand in the leadership of our school. As we launch our new collaborative community, our members will have the unique opportunity to shape and define the role and activities of this important group of volunteers. Potential functions of the Parent Partners will be to develop a Tikkun Olam/Tzedakah program, plan grade level Shabbat and social gatherings at the synagogues and in homes, and organize fundraising efforts to support specific school projects. Parent Partners members will represent the voices of all families and will be in a position to make recommendations towards the activities of the school. All Room Parents will be automatically invited to join the Parent Partners.
*
Would you like to be a part of the Parent Partners?
Please Select One
Yes
No
Hosting a Shabbat Dinner (or other activity)
*
Would your family be interested in hosting a Shabbat dinner or other activity in your home?
Please Select One
Yes
No
Thu, May 9 2024
1 Iyyar 5784
Today's Calendar
Rosh Chodesh Iyyar
ECC
: 7:30am
North Campus - The Nook
: 7:30am
Morning Minyan
: 8:00am
4s Mothers' Day Celebration
: 9:30am
Torah for Today
: 12:00pm
Guys' Night
: 6:30pm
Evening Minyan
: 7:15pm
View Calendar
Thu, May 9 2024 1 Iyyar 5784
